Crossroad Health Center

Job Description
CareCoordination Team Member

Revised: 12/10/2015 by CH

Reviewed Date

/ December, 2015 /

Authorization

/ CEO
Reports To / Program Coordinator

Summary

Work closely with a team of graduate students and young professionals committed to closing the gap between clinical management and selfmanagementfor Crossroad patientswith chronic conditions such as diabetes, hypertension, asthma, and cancer!Team memberscollaborate with patients, families, community partners, health systems, and health plans to coordinate and track care, ensuring that patients have improved care experience, better health outcomes, and decreased health expenditures.

Responsibilities

  • Foster close relationships with patients to close the gap between clinical management and self management for Crossroad patientswith chronic conditions such as diabetes, hypertension, asthma, and cancer through outreach calls and home visits.
  • Collaborate closely with Program Coordinatorto compile, maintain, and risk-stratify disease-based patient case load.
  • Work with providers, health systems, pharmacies, patients, and their families to ensure understanding of and adherence to care plans.
  • Coordinate with payers (Medicaid HMOs, etc.), health systems, pharmacies, community resources, non-profit organizations, and other policy makers in an effort to advocate for, remove access barriers, and address social determinants of health for patients and their families.
  • Utilize local resources to monitor ED use (including but not limited to CCHMC, HealthBridge, etc.).
  • Utilize insurance plan portals to monitor patient utilization and claims.
  • Write grants to expand care provided to patients.
  • Educate patients on the Patient-Centered Medical Home model of care and inform patients about same-day access, preventative care, and on-call resources.
  • Promote efficient, organized and pleasant office operations in the health center and in the community, consistent with the mission of CHC to offer care in an atmosphere of dignity and respect.
  • Uphold all practices for the Health Insurance Portability and Accountability Act (HIPAA).

Knowledge, Experience and Skills

  • Four-year college degree inrelated field preferred.
  • Knowledge of nonprofit environment.
  • Able to work independently, yet seek resources or team assistance when needed.
  • Experience handling a variety of responsibilities and projects.
  • Able and willing to assist with training of volunteers that may be needed.
  • Good organizational skills. Able to coordinate multiple tasks well.
  • Good communication skills, verbal and written.
  • Knowledge of Cincinnati community resources.
  • Proficiency in use of Microsoft, Google drive, and other database systems.
  • Flexible hours to accommodate patient services when required.
  • Willingness to creatively and innovatively problem-solve alongside patients and populations.
  • Spanish language experience preferred.

Acknowledgment

I have read and understand my job description, and I have discussed my job requirements and responsibilities with my supervisor.

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